HEALTH CARE & DEPENDENT CARE FUND
REIMBURSEMENT REQUEST FORM
(Please Print Legibly)
EMPLOYEE INFORMATION
NAME:
EMPLOYEE #:
DAY TIME PHONE #:
CHECK HERE IF NEW ADDRESS
EMAIL ADDRESS:
ADDRESS:
CITY:
STATE:
ZIP:
REIMBURSABLE EXPENSES (Attach documentation)
DATE INCURRED
PROVIDER OF SERVICE (If
Dependent Care service, must
include Tax ID number)
PERSON FOR WHOM SERVICE
PROVIDED
EXPENSE
TYPE
*M or D
REIMBURSEMENT
AMOUNT
REQUESTED
$
$
$
$
$
$
$
TOTAL
$
* EXPENSE TYPE CODE: M = MEDICAL / D = DEPENDENT CARE
NOTE: See Item #5 on Claim Filing Instructions worksheet for Dependent Care requirements, available on the website shown below.
CERTIFICATION
I certify the following is true:
1. The expenses listed above were incurred by me and/or my eligible dependents and qualify for reimbursement. (See Claim
Filing Instructions worksheet available on the website noted below.)
2. The expenses listed above are not eligible for reimbursement by any health care plan.
3. I have not and will not deduct the above listed expenses on my Federal Income Tax returns.
4. The appropriate bills, receipts, Explanation of Benefit statements or documentation for dependent care expenses are
attached or verified by provider signature below.
Employee Signature:
Date:
Signature (provider of dependent care certifying dates and amounts listed above are correct
Date:
for services rendered)
Any person who knowingly and with intent to defraud or deceive any health care plan, files a statement of claim containing any
materially false, incomplete or misleading information is guilty of a crime.
FOR FASTER PROCESSING, FAX TO (501) 225-9153
OR MAIL TO
HealthSCOPE Benefits, Inc.
ATTN: FLEXIBLE SPENDING DEPARTMENT
P.O BOX 350
LITTLE ROCK, AR 72203
FOR MORE INFORMATION ABOUT YOUR
ACCOUNT, PLEASE VISIT OUR WEBSITE:
www.healthscopebenefits.com
WHIRLPOOL CUSTOMER SERVICE
1-800-660-6212